Treatment of diaphyseal forearm fractures in children

Pediatric Forearm Fractures: Investigating the Functional Outcomes of Titanium Elastic Nailing for Unstable Both-Bone Fractures

Introduction

Diaphyseal forearm fractures pose a common challenge in children and adolescents, impacting forearm function due to rotational deformities and angulation. The landscape of pediatric forearm fracture treatment has seen limited progression, with increased surgical intervention adoption driven by factors such as functional implications, technological advancements, societal expectations, and legal concerns.

Materials and Methods

This study enrolled consecutive children aged 5-16 years with forearm fractures presenting between August 2018 and January 2020, requiring surgical intervention. The study assessed functional outcomes and complications in children treated with titanium elastic nailing.

Results

Sixteen patients underwent surgery for both-bone forearm fractures. Elastic nailing was the primary intervention, with 75% undergoing closed nailing. Patients' ages ranged from 5 to 15 years, with 87.5% being male. The study evaluated fracture characteristics, surgical procedures, post-operative care, and complications.

Conclusion

The study demonstrates promising outcomes for flexible intramedullary nailing in pediatric forearm fractures. Despite the observed complications, the majority of cases achieved excellent results in fracture union and patient recovery, supporting the efficacy of this technique. Larger cohorts are needed for a comprehensive understanding of its applicability and outcomes in pediatric forearm fracture management.

Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique

BACKGROUND

Surgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation.

PATIENTS AND METHODS

A retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up.

RESULT

There were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients.

CONCLUSION

In the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.

Functional recovery after reduced pediatric fractures of the forearm with respect to perceived limitations, common post-traumatic symptoms, range of motion, and dexterity: a prospective study

PURPOSE

Studies on functional recovery after pediatric forearm fractures are scarce. Outcome measures are usually (retrospectively) incorporated to compare treatments. How these parameters recover has only rarely fallen within the scope. Aim was to provide insight into "normal recovery" by evaluating how limitations, post-traumatic symptoms, range of motion (ROM) and dexterity recuperate.

MATERIALS AND METHODS

Prospective observational study regarding children 4 and 18 years with a reduced forearm fracture. Limitations, post-traumatic symptoms, ROM, and dexterity were evaluated 6 weeks, 3 and 6 months post-trauma. ROM of the unaffected side was used as a baseline.

RESULTS

Of 54 participants 25.9% and 5.9% perceived limitations after 3 respectively 6 months. Pain, swelling and hypertrichosis were common symptoms. Movements distal from the elbow were restrained 6 weeks post-trauma. Supination and palmar flexion were most affected, followed by dorsal flexion and pronation. Palmar flexion and pronation were still affected after 3 months and associated with treatment invasiveness. Dexterity was diminished at 6 weeks only.

CONCLUSIONS

Mild limitations are common. Further investigation of the association between pain, reduced sensitivity and hypertrichosis with treatment invasiveness is warranted. Regarding ROM supination, pronation, palmar and dorsal flexion should be incorporated in future studies. Dexterity is an unsuitable outcome measure.IMPLICATIONS FOR REHABILITATIONThis study relates to monitoring recovery from pediatric forearm fractures.Physicians ought to realize that one in four children experience limitations preceding 3 months post-trauma, in which case involvement of a hand therapist should be considered.Pain, swelling and especially hypertrichosis are common post-traumatic symptoms in children and should on itself not immediately raise concerns for complex regional pain syndrome (CRPS).To assess recovery of range of motion measuring pronation, supination, dorsal, and palmar flexion is sufficient.

The Risk Factors Associated with Grip Lock Injuries in Artistic Gymnasts: A Systematic Review

Artistic gymnastics (AG) is a sport that demands grace, strength, and flexibility, leading to a broad spectrum of injuries. The dowel grip (DG) is widely used by gymnasts to securely hold onto the high bar or uneven bars. However, incorrect usage of the DG can result in grip lock (GL) injuries. This systematic review aims to (1) identify studies that have investigated the risk factors related to GL injuries among gymnasts and (2) synthesize the key evidence. A comprehensive electronic search was conducted in the following databases: PubMed, ScienceDirect, Elsevier, SportDiscus, and Google Scholar, covering the period from their inception until November 2022. The data extraction and analysis were independently completed by two investigators. A total of 90 relevant studies were initially identified, out of which seven clinical trials met the eligibility criteria. For the quantitative synthesis, five studies were included. The details extracted from each article include: the sample characteristics (number, gender, age, and health status), the study design, the instrumentation or intervention used, and the final results. Our results revealed that the underlying causes of the risk factors of GL injuries were the irregular checking of the dowel grip and the mating surface of the bar, the tearing of the dowel of the leather strap, and the use of the dowel grip in different competition apparatuses. In addition, GL injuries may occur either as severe forearm fractures or mild injuries. Excessive flexion of the forearm and overpronation of the wrist during rotational movements, such as the swing or backward/forward giant circle, may increase the possibility of GL injury on the high bar. Future studies should focus on GL injury prevention strategy and rehabilitation protocol for GL injuries. Further high-quality research is required to establish the validity of these findings.

Change in treatment preferences in pediatric diaphyseal forearm fractures: a Danish nationwide register study of 36,244 fractures between 1997 and 2016

BACKGROUND AND PURPOSE

The choice between invasive and non-invasive treatment of diaphyseal forearm fractures in children can be difficult. We investigated the trends in choice of treatment of pediatric diaphyseal forearm fractures over a 20-year period.  Patients and methods: This is a population-based register study with data from 1997 to 2016 retrieved from the Danish National Patient Registry. The primary outcome was choice of primary treatment within 1 week divided into non-invasive treatment (casting only or closed reduction including casting) and invasive (Kirshner wires, intramedullary nailing [IMN], and open reduction internal fixation [ORIF]). The secondary outcomes were further sub-analyses on invasive treatment and age groups.

RESULTS

36,244 diaphyseal forearm fractures were investigated, yielding a mean incidence of 172 per 105/year. The proportion of fractures treated invasively increased from 1997 to 2016, from 4% to 23%. The use of Kirschner wires increased from 1% to 9%, IMN increased from 1% to 14%, and ORIF decreased from 2% to 1%. The changes were evident in all age groups but smaller in the 0-3-year age group.

CONCLUSION

We found an increase in invasive treatment of pediatric diaphyseal forearm fractures over the investigated period. A change in invasive methods was also found, as the rate of IMN increased over the investigated period and became the predominant surgical treatment choice.

Paediatric forearm fractures: assessment and initial management

The forearm is the most common site of fracture in children. At the time of initial assessment, a thorough examination and neurovascular assessment of the limb is necessary. X-rays allow evaluation of the fracture location and type, in addition to the degree of displacement. With the help of intranasal opiates, manipulation of fracture fragments can be performed in the emergency department. Immobilisation in plaster is the gold standard treatment for paediatric forearm fractures where the degree of displacement is within acceptable parameters. Manipulation and casting should be followed by orthogonal radiographs and a repeated neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge and the child should be reviewed in fracture clinic within a week of the injury. This article reviews the British Orthopaedic Association Standards for Trauma and Orthopaedics for the early management of paediatric forearm fractures that do not require operative management.

Retrospective analysis: risk factors predicting failure of closed reduction in pediatric diaphyseal forearm fractures treated with elastic stable intramedullary nails (ESINs)

LEVEL OF EVIDENCE

Level IV.

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review

BACKGROUND

Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method.

METHODS

MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use.

RESULTS

1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA.

CONCLUSION

Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.

Volar DRUJ Instability After Midshaft Both-Bone Forearm Fracture in a Toddler: A Case Report

CASE

A 2.5-year-old male child presented to the clinic for evaluation of left wrist popping. Ten months earlier, he sustained a closed left both-bone forearm fracture (BBFF) treated with reduction and casting. His clinical course was complicated by redisplacement requiring secondary manipulation and casting before osseous union. His parents reported wrist popping with active motion in the setting of a 20° apex volar malunion of the midshaft radius. He has been treated with observation and monitoring of deformity remodeling.

CONCLUSION

Distal radioulnar joint instability is a potential complication of malunited BBFF, even in a pediatric population. Residual deformity, especially in the radius, should prompt clinical follow-ups after osseous union to assess functional recovery and deformity remodeling.

Rare Presentation of Ulnar Nerve Palsy in Closed Both Bone Forearm Fracture in Pediatric Population

Introduction:

Ulnar nerve injury in closed both bone forearm fracture is rare. Most nerve injuries are neuropraxia and rarely the nerve is trapped or is transected. Most of the time recovery is spontaneous but sometimes requires surgical exploration. We are reporting a case of a 14-year-old boy with closed both bone forearm fracture with ulnar nerve palsy due to entrapment and laceration between ulnar bone fracture fragment.

Case Report:

A 14-year-old boy presented in emergency department elsewhere with a left forearm closed injury due to fall while playing where he was diagnosed with both bone forearm shaft fracture with ulnar nerve palsy and was given an above elbow slab. After 3 days, the patient presented to our outpatient department (OPD) with completely absent sensation over little finger, ulnar aspect of ring finger, and ulnar clawing. No signs of compartment syndrome in the form of tense swelling or stretch pain were seen. There was a suspected ulnar nerve injury for which patient was admitted and posted for fracture fixation and exploration of the nerve in emergency which showed lacerated ulnar nerve trapped in fracture fragment. Open reduction and internal fixation with ulnar plating and radius titanium elastic nailing was done by orthopedic surgeon while ulnar nerve neurolysis and micro repair was subsequently done by plastic surgeon. There was no neurological recovery immediately post-operatively. Patient was discharged after 48 h and called for regular follow-up in OPD to assess fracture union and neurological recovery. There was gradual neurological recovery over the period of time. Complete motor and sensory recovery took place in 4 months.

Conclusion:

Ulnar nerve injury associated with close both bone forearm fracture is uncommon. They are usually associated with a contusion for which the treatment is basically conservative. Immediate nerve exploration and fracture fixation should be reserved for suspicious nerve laceration or entrapment within displaced fracture fragments on radiographs. This prevents delay and also avoids nerve sequelae to occur. Hence, high index of suspicion and complete neurological examination of the patient at first presentation is important to recognize and diagnose the type of nerve lesion early to decide upon the plan of management.

Diaphyseal Both-Bone Forearm Fracture Due to a Grip Lock Injury in a Female Pediatric Gymnast: A Case Report

CASE

A 13-year-old female gymnast sustained a diaphyseal both-bone forearm fracture due to a grip lock injury.

CONCLUSION

This is a report of a diaphyseal both-bone forearm fracture due to a grip lock injury in a female pediatric gymnast, successfully treated with closed reduction and cast immobilization. The rare mechanism of injury, education, and treatment have been discussed.

Elastic intramedullary nail treatment of adolescent perihardware radius and ulna refracture

A 13-year-old girl presented to the clinic with a midshaft refracture of both forearm bones adjacent to the site of a prior forearm fracture that had been treated with plating. She was treated with hardware removal and placement of elastic intramedullary nails. Flexible intramedullary nailing can be successful for a skeletally mature adolescent in treatment of refracture surrounding plate fixation of a midshaft forearm fracture. This technique allows for additional protection of the entire length of the affected bones, while avoiding the extensive dissection needed for extended plating.

Pediatric Open Both-Bone Forearm Fracture Stabilized with Titanium and Stainless Steel Stacked Extension Internal Plating: A Case Report

CASE

A 12-year-old male patient sustained a multisegmental both-bone forearm fracture. Definitive stabilization was ulna intramedullary pinning, with stainless steel plating of the radius followed by a titanium plate stacked atop and extending internal fixation. Currently, 36 months after surgery, he experiences no limitations or complications. All hardware remains in situ.

CONCLUSION

We believe this is the first description of different material plates in direct contact, of stacked plates, and of 1 plate extending another's fixation. No adverse effects developed.

Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature

PURPOSE

This narrative review intends to summarize the most important and relevant data on diagnosis and treatment of pediatric forearm fractures and to describe the characteristics and advantage of each therapeutic option.

METHODS

We conducted a literature research considering peer-reviewed papers (mainly clinical trials or scientific reviews) using the string "forearm fracture AND epidemiology" or "forearm fracture AND diagnosis or " forearm fracture AND treatment" or "forearm fracture AND casting" or "forearm fracture AND surgery". Studies were identified by searching electronic databases (MEDLINE and PubMed) till April 2020 and reference lists of retrieved articles. Only English-language articles were included in the review.

RESULTS

Conservative management with cast immobilization is a safe and successful treatment option in pediatric forearm fractures. Surgical indication is recommended when an acceptable reduction cannot be obtained with closed reduction and casting. Surgical treatment options are intramedullary nail, plating and hybrid fixation.

CONCLUSIONS

There is not a unique consensus about fracture management and treatment. Further studies are necessary to create univocal guidelines about optimal treatment, considering new techniques and available technologies.

Retrograde Fixation of the Ulna in Pediatric Forearm Fractures Treated With Elastic Stable Intramedullary Nailing

Introduction

This study analyzes the outcomes of retrograde fixation of the ulna in pediatric forearm fractures treated with elastic stable intramedullary nailing (ESIN).

Materials and Methods

A retrospective analysis was conducted by reviewing patient records of forearm fractures treated with ESIN by retrograde fixation. The study included 30 children (26 boys and 4 girls). The mean age at the time of injury was 11.7 years (range: 6.6 to 14.3 years). The technique is described. All patients were followed up until hardware removal.

Results

The mean time for fracture healing was 5.3 weeks (range: 4 to 8.8 weeks). The mean time for nail removal was 6.6 months (range: 5 to 10 months). There were five cases with rotation deficits, one of which was a re-fracture.

Conclusions

When antegrade nailing is performed, the ulna is sometimes complicated by non-union as well as entry point irritation. We did not encounter such complications. Retrograde fixation of the ulna in pediatric forearm fractures treated with ESIN is a safe and effective alternative to common fixation (antegrade ulnar fixation) and offers technical advantages.

Recovery of strength after reduced pediatric fractures of the forearm, wrist or hand; A prospective study

Introduction

The way strength recovers after reduction of pediatric fractures of the upper extremity has not previously been the specific scope of research. This is remarkable, since strength measurements are often used as an outcome measure in studies on trauma of the upper extremity. The aim of this study was to evaluate how strength recovers after sustainment of fractures of the forearm, wrist or hand treated by closed or open reduction in children and adolescents in the first 6 months after trauma. How much strength is lost at 6 weeks, 3 months and 6 months after trauma, and is this loss significant? Are there differences in the pattern of recovery between children who underwent a different treatment? And finally, which of the following factors are associated with an increase in the ratio between affected grip strength and expected strength: type of fracture, cast immobilization, occurrence of complications, and degree of pain?

Design

Prospective observational study.

Participants

Children and adolescents aged 4–18 years with a reduced fracture of the forearm, wrist or hand.

Methods

Grip strength, key grip and three-jaw chuck grip were measured twice in each hand 6 weeks, 3 months and 6 months after trauma. Details on fracture type and location, treatment received, cast immobilization and complications were obtained. Hand-dominance and pain were verbally confirmed.

Results

Loss of strength was more prominent and prolonged the more invasive the treatment, hence most extensive in the group receiving open reduction with internal fixation (ORIF), intermediate in the group receiving closed reduction with percutaneous pinning (CRIF), and least extensive in the group undergoing closed reduction without internal fixation (CR). Besides time passed, gender and age were of significant influence on strength, although there was no difference in pattern of recovery over time between children who received a different treatment. In the period of 6 weeks to 3 months after trauma, female gender, type of fracture sustained and occurrence of an unwanted event were associated with an increased ratio between affected and expected grip strength. For the later phase of recovery, between 3 and 6 months, this was only true for the occurrence of an unwanted event.

The evolution of hand function during remodelling in nonreduced angulated paediatric forearm fractures: a prospective cohort study

Forearm fractures are very common orthopaedic injuries in children. Most of these fractures are forgiving due to the unique and excellent remodelling capacity of the juvenile skeleton. However, significant evidence stating the limits of acceptable angulations and taking functional outcome into consideration is scarce. The aim of this study is, therefore, to get a first impression of the remodelling capacity in nonreduced paediatric forearm fractures based on radiological and functional outcome. Children aged 0-14 years with a traumatic angular deformation of the radius or both the radius and ulna, treated conservatively without reduction, were included in this prospective cohort study. Radiographs were taken and functional outcome was assessed at five fixed follow-up appointments throughout a period of one year. Outcome measurements comprised radiographic angular alignment, grip strength and wrist mobility. A total of 26 children (aged 3-13 years) with a traumatic angulation of the forearm were included. Mean dorsal angulation at the time of presentation amounted to 12° (5-18) and diminished after one year to a mean angulation of 4° (0-13). Grip strength, pronation and supination were significantly diminished compared to the unaffected hand up to 6 months after injury. After one year, no significant differences in function between the affected and the unaffected arm were found. Nonreduced angulated paediatric forearm fractures have the potential to remodel in time and have good radiographic and functional outcome one year after trauma, where pronation and grip strength take the longest to recover.

Plaster cast treatment for distal forearm fractures in children: which index best predicts the loss of reduction?

Several radiological indices were introduced to evaluate cast adequacy for paediatric distal forearm fractures: cast, gap, padding, Canterbury (reflecting the cast shape and the amount of padding) and three-point indices, and second metacarpal-radius angle (measuring cast ulnar-moulding). The aim of this study is to define which index is most reliable in assessing cast adequacy and predicting redisplacements. Hundred twenty-four consecutive patients (age 5-18) affected by distal both-bone forearm or radius fractures treated with casting were included. These indices and the displacement angles were calculated on the initial radiograph after reduction. Radiographs at 7 and 30 days were taken to assess if the loss of reduction occurred, and measure the displacement deltas (displacement angle at day 30 - displacement angle at day 0). Student's t-test, Chi-square test and Pearson's correlation were used for the statistical analysis. High padding (P = 0.034), Canterbury (P = 0.002) and Cast (P < 0.001) indices showed an association with redisplacements in distal forearm fractures. Both-bone forearm fractures have a higher risk of loss of reduction than radius fractures [odds ratio (OR = 4.99, 95% confidence interval (CI) = 2.21-11.3, P < 0.001]. A higher displacement delta in antero-posterior (Pearson's r = 0.418, P = 0.037) and lateral (P = 0.045) views for both-bone fractures showed an association with a high gap Index. Regarding radius fractures, a high cast index is associated with a higher displacement delta in antero-posterior (P = 0.035). The three-point index and the second metacarpal-radius angle did not show any association with the redisplacement risk. Cast oval moulding without excessive padding may prevent redisplacements in paediatric distal forearm fractures, while casts ulnar-moulding does not.

Seven-year follow-up for malrotation of a radial diaphysis fracture in a child corrected by osteotomy for loss of motion: A case report

A greenstick fracture is an incomplete fracture where the compressive side of the cortex is still intact but plastically deformed. The incidence of poor results following the closed treatment of greenstick fractures in children >10 years of age is seriously underestimated. Therefore, fixing the position of the forearm is important for initial treatment. In cases of greenstick fracture, the possibility of inadequate remodeling of angulated deformities during growth, and in particular, the lack of correction between rotational malalignment and growth when the diaphyseal forearm is involved in the fracture, should be considered. A male, 10-year-old, left hand-dominant, Asian patient fell while playing in the garden and was immediately assessed by an orthopedic doctor at an Emergency Orthopaedic Clinic. Initial examination revealed a deformity of his dominant left forearm and an angulated greenstick fracture of the radius. However, after 3 months, he developed loss of supination of his left forearm and complained of limitation of left forearm supination. Radiography demonstrated a volar angulation of 20°. The patient underwent open reduction, internal fixation and 10° bending with a plate for correction without corrective rotation. At 12 months after injury, the patient did not exhibit pain or limitation of the elbow and wrist. After follow-up for 7 years, the patient was able to perform normal day-to-day activities with no adverse symptoms. The present case indicated that corrective osteotomy is required following the loss of supination after a greenstick fracture of the diaphysis of the radius. The patient of the current study exhibited rotation due to the central band of the interosseous membrane. In the treatment of greenstick fractures, a radius apex angulation of 20° must be corrected via osteotomy due to loss of rotation. The present case indicated that corrective osteotomy of the radius apex alone without rotational correction, in combination with plate bending improved the loss of forearm rotation.

Ulnar nerve palsy as a complication of closed both-bone forearm fracture in a pediatric patient: a case report

Background: Fractures of both the ulna and radius, known as both-bone forearm fractures are common among the pediatric population. However, ulnar nerve palsy is a rare complication. Nerve damage can be due to multiple factors. Identification of the type of nerve damage is vital for proper management of this complication. Here, we present a case of ulnar nerve palsy complicating a closed both-bone forearm fracture in a pediatric patient. Furthermore, we explored how to best manage such cases and decrease permanent nerve damage through a literature review. Case presentation: A 10-year-old boy presented to the emergency department (ED) 1 day after sustaining a closed right forearm fracture due to a fall. Examination at our ED revealed intact vascularity and nerve function. Reduction and casting were performed. On follow-up 7 days later, signs of ulnar nerve palsy in the form of decreased sensation in the little finger and weak abduction and adduction of the fingers were present. The patient was admitted and underwent closed reduction with percutaneous elastic stable intramedullary nailing. We found 14 case reports in the literature with similar case presentations. These fractures are commonly managed conservatively by closed reduction, casting, and rehabilitation. However, in both-bone forearm fractures, management began with observation, with surgical exploration being reserved for non-improving patients. Conclusion: The uncommon occurrence of ulnar nerve palsy after closed forearm fractures in children should alert physicians to maintain a high index of suspicion and to thoroughly evaluate nerve function in children both before and after reduction of forearm fractures. Surgical exploration is recommended in cases of delayed recovery of nerve function.

Short and long arm cast and pain after discharge in children who underwent reduction of distal forearm fracture in the Emergency Department: A study protocol for a randomized comparative effectiveness study

Distal forearm fracture is the most common fracture in childhood. Patients with this type of injury suffer from meaningful pain after Emergency Department (ED) discharge. Previous studies demonstrated that short arm (below-the-elbow) casts perform as well as long arm (above-the-elbow) casts for maintaining the reduction of distal forearm fractures, with a similar rate of complications. Consequently, short casts are the commonly used method of immobilization after closed reduction of a distal forearm fractures in children older than 4 years. However, short casts carry a potential disadvantage; since they cannot prevent supination in a wrist that is held in pronation, and vice versa, their use might be associated with pain.

We initiated this study to examine the effect of the type of casting on post discharge pain. We will conduct an open-label randomized, controlled trial comparing short cast immobilization with long cast immobilization in children who had a reduction of distal forearm fracture in the ED. Our hypothesis is that children with distal forearm fractures who are treated with a long cast, experience less pain during the first 48 h after ED discharge than children who are treated with a short cast.

Single Bone Fixation versus Both Bone Fixation for Pediatric Unstable Forearm Fractures: A Systematic Review and Metaanalysis

BACKGROUND

It is uncertain whether single bone fixation is comparable to both bone fixation in the treatment of unstable both bone forearm fractures in children.

MATERIALS AND METHODS

A systematic review using PubMed, Embase, and Cochrane Library database searches was performed on October 1, 2015 on English language scientific literature only. Clinical study designs comparing single bone fixation with both bone fixation of pediatric both bone forearm fractures were included. Studies of only one treatment modality were excluded from the study. Studies eligible for inclusion were assessed using the risk of bias tool for nonrandomized studies.

RESULTS

Metaanalysis points to no significant differences in re-angulation, loss of rotation, union time and complications between single bone and both bone fixation. However, the published research lacks quality.

CONCLUSIONS

Despite scattered evidence and small sample sizes, the metaanalysis suggests single bone fixation can be considered a suitable alternative for both bone forearm fractures in children, as it carries less time in surgery and less cost without compromise in final functional outcome compared to double-bone fixation.

Near-anatomical correction using a CT-guided technique of a forearm malunion in a 15-year-old girl: A case report including surgical technique

BACKGROUND

In this case report, we describe a left-arm both-bone forearm fracture in a 15-year-old girl who fell off a swing. Conservative treatment with an above-elbow cast failed, resulting in a malunion with functional impairment. The pro- and supination were 90/0/10, respectively. The patient complained of difficulties performing daily activities. For this pediatric case, a corrective osteotomy was proposed using a CT-guided technique aiming for maximum anatomical and functional outcome. It was the first time this technique was used in our hospital.

METHODS

A corrective osteotomy of the patient's left arm was performed using 3D printed templates to guide the osteotomy orientation. These templates were produced using specialized software in which CT images of her malunited left forearm were overlaid with the mirrored images of her healthy right forearm.

RESULTS

The postoperative CT-scan showed a near-anatomical reduction with close to 1° correction in all three planes, as compared to the preoperative planning. Three months after surgery, the patient had regained full function of her left forearm.

CONCLUSION

Although this was the first time this technique was used in our hospital, it resulted in excellent anatomical and functional outcomes making it a safe, reliable and precise treatment option that may be useful for even more complex corrections.

LEVEL OF EVIDENCE

Level V.

Stacked Flexible Nailing for Radius Ulna Fractures: Revival of a lost Technique

Introduction:

Simultaneous radius and ulna fractures are common in adults and generally osteosynthesis with plating is the treatment of choice. Nailing of such fractures is infrequently advocated. We present our unique technique of radius ulna nailing in adults to achieve closed reduction and early predictable union with minimal or no complications.

Case Report:

Case 1: 22 year old male with midshaft both bones forearm fracture was treated with stacked nailing. Two 2.5 mm steel elastic nails were used in each radius and ulna. No post-operative splintage was needed and patient was mobilized immediately. Patient was able to go back to work in 2 weeks and at one year follow up he showed excellent functional outcome.

Case 2: Fifteen year old boy presented with midshaft both bone fractures secondary to fall from height. He was also treated with stacked flexible nailing. Good stability was achieved and patient was mobilized immediately without any splints. He was able to write his exams which started on 11th day post-surgery and could complete his theory papers. At final follow up both bones united with good callus and no functional limitations.

Conclusion:

Stacked nailing technique is a good option in midshaft transverse or short oblique fractures of radius and ulna. It allows for early mobilization without brace or splint. With proper patient selection, good results can be obtained by this simple and minimally invasive technique.

Predictive factors for re-displacement in diaphyseal forearm fractures in children-role of radiographic indices

Background and purpose - Manipulation and cast immobilization is the primary management for diaphyseal forearm fractures in children, and re-displacement is the most common complication. We wanted (1) to analyze the incidence of re-displacement in a group of children treated with close reduction and casting; (2) to determine predictive factors such as demographics, mechanism of injury, affected bone, fracture pattern, degree of initial displacement and angulation, and reduction accuracy; and (3) to determine the prognostic effect of previously defined radiographic indices. Patients and methods - We prospectively studied 269 consecutive children with closed and complete middle-third diaphyseal fractures treated with close reduction and casting from October 2014 to April 2015. Factors analyzed included demographics, initial fracture features, having a non-anatomical reduction, and the radiographic indices of cast quality. Results - There were 189 fractures of both bones (70%) and 80 solitary fractures (30%). The overall re-displacement rate was 11%. According to multivariable analysis, independent predictors of re-displacement were initial angulation >10° (RR =5) and failure to achieve an anatomical reduction (RR =2). Statistically significant radiographic indices regarding increased rate of re-displacement included cast index ≥0.7 (RR =5), Canterbury index ≥1.1 (RR =3), and 3-point index ≥0.8 (RR =6). Interpretation - Our results suggested that fractures with a higher degree of initial angulation and non-anatomical reduction more often result in re-displacement. Moreover, the casting quality examined with the radiographic indices played an important role in the success of a non-operative management.